Protected: Qi08 – Broad- to narrow-spectrum antibiotics

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Operationalisation

Denominator

The amount of narrow-spectrum penicillins, cephalosporins and erythromycin (ATC groups J01(CA+CE+CF+DB+FA01)), in DDDs per year (1).

Numerator

The amount of broad-spectrum penicillins, cephalosporins, macrolides (excl. erythromycin) and fluoroquinolones (ATC J01(CR+DC+DD+(FA–FA01)+MA)), in DDDs per year (1)

Exclusions (Numerator, denominator)

N/A

Notes

Consumption is examined in defined daily doses (DDDs). DDD is the assumed average maintenance dose per day for a medication used for its main indication in adults (1).

Sources of Data

(Whole)sales data (outpatient and inpatient) or other registers with total consumption

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Similar or related indicators in Nordic or European quality assessment

  • The European Centre for Disease Prevention and Control (ECDC), the European Food Safety Authority (EFSA) and the European Medicines Agency (EMA) jointly established a list of harmonised outcome indicators for antimicrobial consumption and antimicrobial resistance (15)
    • The ratio of consumption of broad-spectrum penicillins,cephalosporins, macrolides and fluoroquinolones (J01(CR+DC+DD+(F-FA01)+MA)) to the consumptionof narrow-spectrum penicillins, cephalosporins and macrolides (J01(CA+CE+CF+DB+FA01)) was recommended as secondary indicator, to reflect antimicrobial consumption in the community.
  • The European Centre for Disease Prevention and Control (ECDC) uses European data reported to the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) for monitoring antimicrobial consumption (1).
    • The ratio of consumption of broad- to narrow-spectrum antibiotics is included as a secondary outcome indicator, to describe patterns of antimicrobial consumption in the community sector.

Similar or related indicators in international scientific literature

  • Ratio of the consumption of broad (J01(CR+DC+DD+(F-FA01))) to the consumption of narrow spectrum penicillins, cephalosporins and macrolides (J01(CE+DB+FA01))(5)
  • Children (up to 14/18 yrs) in primary care: The ratio between the number of users of broad spectrum [J01CR, J01DC, J01DD and J01F (without erythromycin)] to those of narrow-spectrum penicillins, cephalosporins and macrolides (J01CE, J01DB and J01FA01), stratified by country, age categories and calendar year. The smaller the B/N ratio, the most appropriate the prescribing (16)
  • Ratio of the consumption of broad-spectrum antibiotics to the consumption of narrow-spectrum penicillins, cephalosporins and macrolides (17)
  • Ratio of prescriptions of amoxicillin (J01CA04) to second-line antibiotics (amoxicillin-clavulanic acid (J01CR02) + quinolones (J01M) + cephalosporins (J01D) + macrolides, lincosamides, streptogramins and ketolides (J01F)). Target: > 1 (18,19)
  • Amoxicillin/amoxicillin clavulanate (ratio) among dentist prescriptions: No. of prescriptions of amoxicillin (J01CA04) / No. of prescriptions of amoxicillin clavulanate (J01CR02) (20)

References

  1. Antimicrobial consumption in the EU/EEA (ESAC-Net) – Annual Epidemiological Report for 2022 [Internet]. 2023 [cited 2024 May 2]. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-consumption-europe-2022
  2. ATCDDD – Definition and general considerations [Internet]. [cited 2024 May 2]. Available from: https://atcddd.fhi.no/ddd/definition_and_general_considera/
  3. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, et al. The Relationship between Antimicrobial Use and Antimicrobial Resistance in Europe. Emerg Infect Dis. 2002 Mar;8(3):278–82.
  4. Browne AJ, Chipeta MG, Haines-Woodhouse G, Kumaran EPA, Hamadani BHK, Zaraa S, et al. Global antibiotic consumption and usage in humans, 2000–18: a spatial modelling study. Lancet Planet Health. 2021 Dec 1;5(12):e893–904.
  5. Coenen S, Ferech M, Haaijer-Ruskamp FM, Butler CC, Vander Stichele RH, Verheij TJM, et al. European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual Saf Health Care. 2007 Dec;16(6):440–5.
  6. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet. 2005 Feb 12;365(9459):579–87.
  7. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. The Lancet. 2007 Feb 10;369(9560):482–90.
  8. Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach 2023/C 220/01 [Internet]. 2023. Available from: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32023H0622(01)
  9. Johnson A, Russell L, Perry JD, Slavin M, Tacconelli E. Preface. J Antimicrob Chemother. 2021 Jul 1;76(Supplement_2):ii1.
  10. Demeke CA, Adinew GM, Abebe TB, Gelaye AT, Gemeda SG, Yimenu DK. Comparative analysis of the effectiveness of narrow-spectrum versus broad-spectrum antibiotics for the treatment of childhood pneumonia. SAGE Open Med. 2021;9:20503121211044379.
  11. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic Prescribing in Ambulatory Pediatrics in the United States. Pediatrics. 2011 Dec 1;128(6):1053–61.
  12. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  13. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  14. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  15. Ecdc EP on BH (BIOHAZ), Use (CVMP) EC for MP for V. ECDC, EFSA and EMA Joint Scientific Opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and antimicrobial consumption in humans and food-producing animals. EFSA J. 2017;15(10):e05017.
  16. de Bie S, Kaguelidou F, Verhamme KMC, De Ridder M, Picelli G, Straus SMJM, et al. Using Prescription Patterns in Primary Care to Derive New Quality Indicators for Childhood Community Antibiotic Prescribing. Pediatr Infect Dis J. 2016 Dec;35(12):1317–23.
  17. Pont LG, Morgan TK, Williamson M, Haaijer FM, van Driel ML. Validity of prescribing indicators for assessing quality of antibiotic use in Australian general practice. Int J Pharm Pract. 2017 Feb;25(1):66–74.
  18. Thilly N, Pereira O, Schouten J, Hulscher ME, Pulcini C. Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2020 Jul;25(27):1900468.
  19. Thilly N, Pereira O, Schouten J, Hulscher MEJL, Pulcini C. Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data. JAC-Antimicrob Resist. 2020 Oct 22;2(4):dlaa086.
  20. Simon M, Pereira O, Guillet-Thibault J, Hulscher MEJL, Pulcini C, Thilly N. Design of Proxy Indicators Estimating the Appropriateness of Antibiotics Prescribed by French Dentists: a Cross-Sectional Study Based on Reimbursement Data. Antimicrob Agents Chemother. 2021 Apr 19;65(5):10.1128/aac.02630-20.
  21. Simon M, Pereira O, Hulscher MEJL, Schouten J, Thilly N, Pulcini C. Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data. Clin Infect Dis. 2021 May 15;72(10):e493–500.